M. N. Mustian1, B. A. Shelton1, R. M. Hungerpiller1, D. L. Sawinski2, R. D. Reed1, P. A. MacLennan1, J. E. Locke1 1University Of Alabama At Birmingham,Birmingham, AL, USA 2University Of Pennsylvania,Philadelphia, PA, USA
Introduction: Hepatitis C virus (HCV) positive kidney transplant (KT) candidates can be successfully treated with direct acting antivirals (DAAs) either pre- or post-transplantation. However, following treatment for HCV, patients lose access to HCV+ organs, which are associated with significantly shorter time to transplant. The purpose of this study was to determine the most cost-effective treatment option for this patient population.
Methods: A Markov model comparing two strategies (pre vs. post-transplant treatment with DAAs) was developed using probabilities from the Scientific Registry of Transplant Recipients (SRTR) database and published literature with a three-year time horizon. Costs were expressed in 2017 US dollars from the societal perspective, and utility was measured in quality-adjusted life years (QALYs). Strategies were compared using incremental cost-effectiveness ratios (ICERs). One-way probabilistic sensitivity analyses were conducted.
Results: When the probability of undergoing KT within 3 years of listing while HCV+ was less than 50%, the cost-effectiveness of pre-transplant DAA therapy was $136,073/QALY, compared with $179,135/QALY for post-transplant HCV treatment. DAA treatment post-transplant was dominated (i.e. more costly while yielding less benefit), with an ICER of -$679,290/QALY. Given a >50% probability of transplantation within 3 years of listing while HCV+, pre-transplant treatment had an associated cost of $138,320/QALY, while post-transplant treatment was $151,302/QALY. However, treatment post-transplant was no longer dominated (ICER: $235,670/QALY), indicating greater effectiveness of treating HCV post-transplant.
Conclusion: These preliminary analyses suggest that as the probability of transplantation while HCV+ increases, the strategy to treat HCV with DAAs post-transplant becomes more cost-effective. When the probability of receiving a KT while HCV+ within 3 years was <50%, DAA therapy pre-transplant is more cost-effective. Conversely, HCV+ candidates at centers with >50% probability of KT achieve greater benefit from post-transplant DAA treatment. Moreover, these findings indicate that the cost-effectiveness of the two distinct treatment approaches may be affected by wait list times at the center-level, but further analysis is still needed, accounting for other potential cofounders such as progression to liver disease and coinfection with HIV.